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Federal forms, ICRs, and supporting documents

Information Collection

Women's Preventive Health Services Survey

IC 225622 under ICR 201702-0920-004 · OMB 0920-1200.

Documents and Forms
Document Name
Document Type
Form
Form
Form
Form
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Women's Preventive Health Services Survey
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form none WPHSS questionnaire Attachment 3. WPHSS_Survey with consent_English.docx Yes Yes Fillable Fileable
Form none Survey screenshots - English Attachment 6. WPHSS_Survey Screenshots_English.pdf Yes Yes Fillable Fileable
Form none Survey screenshots - Spanish Attachment 7. WPHSS_ Survey Screenshots_Spanish.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

2,338 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 2,338 0 2,338 0 0 0
Annual IC Time Burden (Hours) 974 0 974 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Web instructions Attachment 5. WPHSS_Web Instructions Bilingual.docx 02/08/2017
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.